Doctors' orders: healthcare architecture, too often a functionalist response to short-term budgeting, should increasingly be based on the wealth of evidence about how patients respond to different physical environments

Architectural Review, The, May, 2005 by Paul Finch

What sort of hospitals do we want in the twenty-first century, how might they differ from those of the recent past, and why would we change them? In March 2002, AR carried an article on evidence-based design which showed that certain environments would help patients recover more quickly, using fewer drug treatments. That sort of research continues, and continues to confirm what every patient knows: that physical environment has an effect on the way you feel; and as every doctor knows, the way you feel has an effect on your state of both mind and health. The dilemma for designers, both generalists and specialists, is how to synthesise the increasing body of knowledge about the relationship between design and well-being with the requirements of those who commission hospitals. It is all very well saying that every patient should have their own room with their own nurse and (to exaggerate) their own personal physician on call twenty-four hours a day. Life is not like that. But how close would it be possible to come to the civilised environment for patient, staff and visitor without incurring costs disproportionate to the improvements achieved?

Britain's National Health Service, one of the world's biggest organisations with a nursing staff of 365 000, has been reviewing this in the light of the extraordinary programme of healthcare building now under way, with 100 new hospitals likely to be completed in the next five years. It has had the benefit of advice from Professor Roger Ulrich, currently on sabbatical from the US and working with NHS Estates, who has been a pioneer in this field for many years. At a recent UK conference (1) the professor and his British architectural ally Richard Burton outlined the attributes of what he and fellow researchers, medical, architectural and financial, have dubbed the 'Fable Hospital', a composite of recently completed or upgraded hospitals where evidence-based design principles have been employed. (2)

Such a composite would include a series of elements which, in combination, would produce a building which is safer, patient-focused, family-friendly, cost-sensitive and offering high levels of staff amenity. Specifically, Fable would have oversized single rooms with dedicated space for patient, family and staff activities; sufficient capacity for in-room procedures; and maximised daylight exposure. Acuity rooms would be standardised in shape, size and technology-friendly headwall, eliminating the need to move patients as their conditions change. Bathrooms would have double-door access to help carers and staff assist patients on foot, in wheelchairs or in bed. Decentralised, barrier-free nursing stations would place nurses in close proximity to patients and supplies, most stored nearby. Alcohol-rub hand hygiene dispensers would be located at the bedside of each patient room to reduce staff-to-patient pathogens. Filters would be used to improve filtration of outside air and eliminate re-circulated air.

In respect of softer environmental issues, the new model hospital would include peaceful environments with artwork displays, space to listen to piano music (apparently more soothing than other sorts), and gardens with fountains and benches. Noise-reduction measures would include sound-absorbing floors and ceilings and wireless communication systems. Patient education centres would be created on each floor giving patients and relatives a greater understanding of illness. On the staff front, support facilities would include a staff-only cafeteria, windowed break rooms with outside access, and a health club.

This composite picture represents an architectural and product design response to patient-based or evidence-based design: the question inevitably asked is in relation to the robustness of the evidence. Roger Ulrich and others scoured the academic world for research papers in the field, finding more than 600 relevant to their quest. (3) They posit the design equivalent of evidence-based medicine, that repeated use with repeated successful results means a causal link. They acknowledge the difficulty to identify the impact of single elements within a complex system like hospital care, but the impressive weight of evidence they cite makes it imperative that any architect working on healthcare projects digests the conclusions they have reached. The conclusions will make uncomfortable reading for those health procurers and designers wedded to the primacy of the ward over single rooms (except in the case of children's hospitals, where the reverse seems to be true), and for those institutions where hygiene arrangements in a world of cross-infection are inadequate. There is no excuse for the latter, and the research about what happens if the facts are ignored is there too.

In the US, of course, the threat of litigation concentrates the minds of health administrators, and sets pulses racing among hospital finance directors. Can it really be true that additional spending to produce better, safer hospitals can result in paybacks of only 12 months, excluding any savings, as a result of less litigation? Ulrich cites the work of Professor Leonard Berry and others (2) which shows just this: in their Fable Hospital model, the hypothetical initial construction cost of $240 million was increased by $12 million to take account of the enhanced facilities outlined above. Financial appraisals carried out by hospital CEOs suggested that the additional costs would be recovered in year one, and that savings would accrue from that time on. This would sound extraordinary, and possibly fantastical, were it not for the fact that the financial models have been checked by professionals with no aesthetic axe to grind.